Download Immobility, Skin Integrity, and Wound care

Immobility, Skin Integrity, and Wound Care
Dr. Belal Hijji, RN, PhD
March 31, April 1 & 7, 2012
Learning Outcomes
At the end of this lecture, students will be able to:
• Define relevant terms
• Discuss the effects of immobility on body systems
• List classifications of pressure ulcers
• Discuss factors contributing to pressure ulcer formation
• Describe the three major classifications of dressings and rules
of wound care
• Discuss the medical and nursing management of wound care
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Immobility- Definition of Terms
• Mobility: Is the person’s ability to move around freely in his/
her environment.
• Immobility: Inability to move around freely. Whether
immobility causes any problems often depends on the duration
of inactivity, the client’s health status, and his/ her sensory
awareness
• Bed rest: Is an intervention in which the client is restricted to
bed for therapeutic reasons.
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Effects of Immobility
• Musculoskeletal system
– Disuse osteoporosis: Without the stress of weight-bearing
activity, the bones deminerlise. Calcium decreases, the bones
become spongy, may gradually deform and fracture easily.
– Disuse atrophy: Unused muscles atrophy (decrease in size)
losing most of their strength and normal function.
– Contractures: When the muscle fibers are not able to shorten or
lengthen, a contracture (permanent shortening of the muscle)
forms, limiting joint mobility (See figure1).
– Stiffness and arthralgia: Without
movement, the connective tissue
at a joint becomes ankylosed
(permanently immobile). As bones
dimineralise, excess calcium may
move to joints, contributing to stiffness and pain,
Figure 1: Contractures
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• Cardiovascular system
– Diminished cardiac reserve: Decreased mobility can lead to
increase in heart rate. Rapid heart rate reduces diastolic pressure,
coronary blood flow, and the capacity of the heart to respond to
any metabolic demands above the basal level. Because of this
diminished cardiac reserve, the immobilised person may
experience tachycardia with minimal exertion.
– Increased use of Valsalva maneuver: This maneuver refers to
holding the breath and straining against a closed glottis. For
example, a client tends to hold breath when trying to move up in
bed. This builds up sufficient pressure on the large veins in the
thorax to interfere with blood flow to the heart and coronary
arteries. During exhalation, the glottis again opens, pressure is
suddenly released, and a surge of blood flows to the heart.
Tachycardia and cardiac arrhythmias can result in clients with
cardiac disease.
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– Orthostatic hypotension: Under normal condition,
vasoconstriction prevents pooling of the blood in legs and
maintains central blood pressure. During prolonged immobility,
this reflex becomes dormant. When an immobile person tries to
sit or stand, this reconstricting mechanism fails to function
properly. The blood pools in the lower extremities, and central
blood pressure drops. Cerebral perfusion is seriously
compromised, and the person feels dizzy and may faint [ ‫يغمى‬
‫]عليه‬
– Thrombus formation: Three factors collectively predispose a
client to the formation of thrombophlebitis (a clot that is loosely
attached to an inflamed vein wall): impaired venous return to
heart, hypercoagulability of blood, and injury to a vessel wall. A
thrombus (Figure 2) is dangerous if it breaks loose from the vein
wall to enter the general circulation an embouls (an object that
has moved from its place of origin, causing obstruction to
circulation elsewhere).
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Figure 2: Blood clot
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• Respiratory system
– Decreased respiratory movement: In a recumbent, immobile
client, the body presses against the rigid bed and curtails chest
movement. The abdominal organs push against the diaphragm,
restricting lung movement and making it difficult to expand the
lungs fully. As a result, shallow respirations are produced and
vital capacity (the maximum amount of air that can be exhaled
after maximal inhalation) is reduced.
– Pooling of respiratory secretions: Immobility allows secretions
to pool by gravity, interfering with normal diffusion of oxygen
and carbon dioxide in the alveoli. The ability to cough up
secretions may be hindered by loss of respiratory muscle tone,
dehydration, or sedatives that depress cough reflex. Poor
oxygenation and retention of carbon dioxide in the blood can
lead a potentially fatal respiratory acidosis.
– Hypostatic pneumonia: pooled secretions are an excellent media
for bacterial growth leading to pneumonia. This condition can
severely impair oxygen-carbon dioxide exchange and may be
lethal.
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• Urinary system
– Urinary stasis: In immobile person, gravity impedes the
emptying of urine from the kidneys and the bladder. To urinate, a
person in supine position must push upward against gravity. The
renal pelvis may fill with urine before it is pushed into the
ureters. Empting is not complete and urinary stasis (urine flow is
stopped or slowed down) occurs a few days of bed rest.
Therefore, bladder emptying is further compromised.
– Renal stones: With immobility, there is excessive amounts of
calcium in the urine. Calcium salts precipitate out as crystals to
form renal calculi.
• Integumentary system
– Skin breakdown: Immobility impedes circulation and diminishes
the supply of nutrients to specific area. This results in skin
breakdown and formation of pressure ulcer.
• GIT system
– Constipation: Occurs due to decreased peristalsis and colon
motility. The overall skeletal muscle weakness affects the
abdominal and perineal muscles used in defecation.
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Skin
• Has three layers (Fig. 3):
– Epidermis: the outer visible layer, contains keratin, an extremely
tough, protective protein substance that can cause tissue to
become hard or horny.
– Dermis: The deeper dermis is made up of proteins and
mucopolysaccharides, thick, gelatinous material that provides a
supporting matrix for nerve tissue, blood vessels, sweat and
sebum glands, and hair follicles.
– Subcutaneous tissue: This layer is made up of fatty connective
tissue. Together, the layers of the skin protect underlying
structures from physical trauma and ultraviolet (UV) radiation.
The skin is essential to maintaining body temperature, fluid
balance, and sensation. It is involved in absorption and excretion,
immunity, and the synthesis of vitamin D from the sun.
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Figure 3: Structures of the skin
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Skin Integrity and Wound Care – Pressure Ulcer
Classification of pressure ulcers
Stage I is the most superficial, indicated by non blanchable redness that
does not subside after pressure is relieved. This stage is visually similar to
reactive hyperemia seen in skin after prolonged application of pressure.
Stage II is damage to the epidermis extending into, but no deeper than, the
dermis. In this stage, the ulcer may be referred to as a blister or abrasion.
Stage III involves the full thickness of the skin and may extend into the
subcutaneous tissue layer. This layer has a relatively poor blood supply and
can be difficult to heal.
Stage IV (Figure 4) pressure ulcer: Stage IV is the deepest, extending into
the muscle, tendon or even bone.
Unstageable pressure ulcers are covered with dead cells, or eschar and
wound exudate, so the depth cannot be determined.
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Figure 4: Stage IV pressure ulcer
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If untreated, a pressure sore can progress from a small irritated but unbroken skin
patch to a potentially life-threatening wound involving extensive tissue death and
infection. Treatment of the serious decubitus ulcer may include debriding
(excising) the dead tissue and administering systemic antibiotics.
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Contributing Factors to Pressure Ulcer Formation
In addition to pressure, other factors can increase the risk for
developing pressure ulcers. These are:
– Shear: Is the force exerted against the skin while skin remains
stationary and the bony structures move. For example, when
elevating the HoB, gravity causes the bony skeleton to pull
toward the foot of bed, while the skin remains against the
sheets. This process impedes circulation to deep tissues.
– Friction: Is an injury to the skin that has the appearance of an
abrasion (Figure 5a & b). Elbows and heels are at risk for
friction because abrasion of these surfaces can occur when they
are rubbed against sheets during repositioning.
– Moisture: Moisture on the skin increase the risk of ulcer
formation. Moisture reduces the skin’s resistance to pressure or
shear.
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– Nutrition: Poor nutrition can cause soft tissue to become
susceptible to breakdown. Low protein levels cause edema,
which contributes to problems with oxygen and nutrients
transport. Edema increases the affected tissue risk for pressure
ulcer formation. Blood supply to edematous areas is decreased,
and waste products remain.
– Infection: Fever results in sweating and increased moisture,
which predispose to skin breakdown.
– Age: Older adults are at higher risk for development of pressure
ulcer because of loss of dermal thickness and an increase in the
risk of skin tear.
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Figure 5a:Abrasions on elbow and lower
arm. The elbow wound will produce a
permanent scar.
Figure 5b:Abrasion on the palm
of a right hand, shortly after
falling.
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What is a Scar?
• A scar (Figure 6) is an area of fibrous [‫ ]ليفي‬tissue (fibrosis)
that replaces normal skin after injury. A scar results from the
biological process of wound repair in the skin and other tissues
of the body. Thus, scarring is a natural part of the healing
process. With the exception of very minor lesions, every
wound (e.g. after accident, disease, or surgery) results in some
degree of scarring.
Figure 6: A minor scar from a cut to the forearm, approx. one year since the wound.
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Wound Care
• There are three major classifications of dressings for skin
conditions:
– Wet
– Moisture-retentive
– Occlusive
• These classifications will be discussed after presenting
dressings and rules of wound care
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Dressings and Rules of Wound Care
• Rule 1: Categorization. The nurse should learn about
dressings by generic category because hundreds of choices are
now available. The nurse should also develop a systematic
approach to product selection, and should be familiar with
indications, contraindications, and side effects.
• Rule 2: Selection. The nurse should select the safest and most
effective, user-friendly, and cost-effective dressing possible.
Nurses should be prepared to give the physician feedback
about the dressing’s effect on the wound and ease of use for
the patient.
• Rule 3: Change. The nurse changes dressings based on
patient, wound, and dressing assessments, not on standardized
routines, such as three or four times each day.
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Dressings and Rules of Wound Care
• Rule 4: Evolution. As the wound healing process progresses,
the dressing protocol is altered to optimize healing. The nurse
and patient have access to a wide variety of products and
knowledge about their use. The nurse teaches the patient about
wound care and ensures that the family has access to
appropriate dressing choices.
• Rule 5: Practice. Practice with dressing material is required
for the nurse to learn the proper way of performing a particular
dressing. Refining the skills of applying appropriate dressings
correctly and learning about new dressing products are
essential nursing responsibilities. Dressing changes should not
be delegated to assistive personnel.
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Classifications of Dressings
Wet Dressings
• Wet dressings (ie, wet compresses applied to the skin) are
sterile or nonsterile, depending on the skin disorder. They are
used to reduce inflammation by producing constriction of the
blood vessels; to clean the skin of exudates [cellular waste
product]and pus; to maintain drainage of infected areas; and to
promote healing by facilitating the free movement of
epidermal cells across the involved skin so that new
granulation tissue forms.
• Before dressings, the nurse washes hands and puts on sterile or
clean gloves. The open dressing requires frequent changes
because evaporation is rapid. The closed dressing is changed
less frequently, but there is always a danger that the closed
dressing may cause actual maceration [soften by soaking] of
the underlying skin. The dressing remains in place until it
dries. It is then removed without soaking so that exudate, or
pus from the wound adhere to the dressing and are removed
with it.
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Classifications of Dressings
Moisture-Retentive Dressings
• Moisture-retentive dressings have similar functions as those of
wet dressing but are more efficient at removing exudate; some
have reservoirs that can hold excessive exudate.
• The main advantages of moisture-retentive dressings over wet
compresses are reduced pain, fewer infections, less scar tissue,
gentle autolytic débridement [A process that uses the body’s
own digestive enzymes to break down necrotic tissue], and
decreased frequency of dressing changes. Several available
products contain enzymatic débriding agents; examples
include Accu Zyme, collagenase, (Santyl), Granulex, and
Zymase. Application of these products speeds the rate at which
necrotic tissue is removed.
• Depending on the product used and the type of skin problem,
most moisture-retentive dressings may remain in place from
12 to 24 hours; some can remain in place as long as a week.
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Classifications of Dressings
Occlusive Dressings
• Occlusive dressings may be commercially produced
inexpensively from sterile or nonsterile gauze squares.
• Occlusive dressings cover topical medication that is applied to
a abnormal skin lesion. The area is kept airtight by using
plastic film (eg, plastic wrap), which is thin and readily adapts
to all sizes, body shapes, and skin surfaces. Generally, plastic
wrap should be used no more than 12 hours each day.
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Medical Management
Therapeutic Baths (Balneotherapy) and Medications
• Baths, known as balneotherapy, are useful when large areas of
skin are affected. The baths remove crusts, scales, and old
medications and relieve the inflammation and itching that
accompany acute dermatoses [skin diseases]. The water
temperature should be comfortable, and the bath should not
exceed 20 to 30 minutes because of the tendency of baths and
soaks to produce skin maceration.
• Because skin is easily accessible, topical medications are often
used. High concentrations of some medications can be applied
directly to the affected site with little systemic absorption and
therefore with few systemic side effects. Because topical
preparations may induce allergic contact dermatitis in sensitive
patients, any untoward response should be reported
immediately and the medication discontinued.
Continued…..
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• Lotions, creams, ointments, and powders are frequently used
to treat skin lesions. In general, moisture-retentive dressings,
with or without medication, are used in the acute stage; lotions
and creams are reserved for the subacute stage; and ointments
are used when inflammation has become chronic and the skin
is dry with scaling.
• With all types of topical medication, the patient is taught to
apply the medication gently but thoroughly and, when
necessary, to cover the medication with a dressing to protect
clothing.
• Intralesional Therapy. Intralesional therapy consists of
injecting a sterile medication (usually a corticosteroid) into or
just below a lesion. Skin lesions treated with intralesional
therapy include psoriasis, keloids, and acne vulgaris.
• Systemic Medications. These include corticosteroids for shortterm therapy for contact dermatitis or for long-term treatment
of a chronic dermatosis, such as pemphigus vulgaris. Other
frequently used systemic medications include antibiotics,
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antifungals, antihistamines, and analgesics.
Acne vulgaris
Psoriasis
Keloid
Pemphigus vulgaris is an autoimmine
disorder, where the body's immune
system attacks some of the proteins in
the skin. This picture shows a close-up
of the blistering on the back. Most of
the blisters have broken, which is
common since these blisters are
fragile.
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Nursing Management
• Management begins with a health history, direct observation,
and a complete physical examination.
• Because of its visibility, a skin condition is usually difficult to
conceal from others and may cause the patient some emotional
distress.
• The major goals for the patient may include maintenance of
skin integrity, relief of discomfort, promotion of restful sleep,
self-acceptance, knowledge about skin care, and avoidance of
complications.
• Nursing management for patients who must perform self-care
focuses mainly on teaching them how to wash the affected
area and pat it dry, apply medication to the lesion while the
skin is moist, cover the area with plastic if recommended, and
cover it with an elastic bandage, dressing, or paper tape to seal
the edges.
• Dressings that contain or cover a topical corticosteroid should
be removed for 12 of every 24 hours to prevent skin thinning
(ie, atrophy), striae, and telangiectasia (ie, small, red lesions
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caused by dilation of blood vessels).